24-4 ics terminology cardozo

Standardisation of Terminology of Lower Urinary Tract Function : 

Standardisation of Terminology of Lower Urinary Tract Function Linda Cardozo MD FRCOG Professor of Urogynaecology King’s College Hospital London

Standardisation of Terminology : 

Standardisation of Terminology Why do we need it? Words mean different things depending on context, nationality, age, professional status Clinical communication Scientific reporting Comparison of information Avoidance of litigation

International Continence Society : 

International Continence Society ICS = Intensive Care Society Institute of Chartered Shipbrokers Institute of Customer Services Integrated Computer Solutions Information and Computer Services Intercontinental Church Society Irish Computer Society

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Manneken Pis - Brussels

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Communication Favourite words 72 boys and 28 girls aged 7.2 (2 – 16) years on a paediatric surgical ward and in out-patients asked to name four body parts (penis, vagina, anus, testicles) and four bodily functions (defaecation, anal flatulence, micturition, vomiting) Wide variety of “favourite words” (willy, fanny, bum, balls) and (pooh, fart, wee wee, sick) commonest. However massive variation e.g. one 6 year old boy did a “charlie”, “let polly out”, and possessed a “dilly dat”. McDonald, et al (1985)

Political Correctness : 

Political Correctness Genuine stress incontinence How can incontinence not be “genuine”? Now referred to as urodynamic stress incontinence Detrusor instability/unstable bladder Patients do not like to be considered “unstable” Now referred to as detrusor overactivity / overactive bladder

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Symptoms and Symptom Syndromes Signs Urodynamic Observations Conditions ICS Terminology 2002

Symptoms : 

Symptoms volunteered or described during interview qualitative cannot usually be used for definitive diagnosis can indicate other pathology eg UTI Symptoms are the subjective indicator of a disease or change in condition as perceived by the patient, carer or partner and may lead him/her to seek help from health care professionals.

Lower Urinary Tract Symptoms : 

1.1 Storage symptoms 1.2 Voiding symptoms 1.3 Post micturition symptoms 1.4 Symptoms associated with sexual intercourse 1.5 Symptoms associated with pelvic organ prolapse 1.6 Genital and LUT pain 1.7 Genito urinary pain syndromes and symptom syndromes suggestive of LUT Dysfunction (LUTD) Lower Urinary Tract Symptoms

ICS Definitions of Incontinence : 

ICS Definitions of Incontinence “Urinary incontinence is the complaint of any involuntary loss of urine.” ICS 2002 “Urinary incontinence is the involuntary loss of urine that is a social or hygienic problem.” ICS 1988

ICS Incontinence : 

ICS Incontinence Specify relevant factors: Type Frequency Effect on quality of life

ICS Definition of stress urinary incontinence : 

ICS Definition of stress urinary incontinence Definition Stress urinary incontinence is the complaint of involuntary leakage of urine on effort or exertion, or on sneezing or coughing.

Storage Symptoms (ICS 2002) : 

Storage Symptoms (ICS 2002) Urgency - is the complaint of a sudden compelling desire to pass urine, which is difficult to defer Urge(ncy) incontinence - is the complaint of involuntary leakage accompanied by or immediately preceded by urgency Frequency - is the complaint by the patient who considers that he/she voids too often by day Nocturia - is the complaint that the individual has to wake at night one or more times to void

ICS Definition of Urgency(NUU 2002) : 

ICS Definition of Urgency(NUU 2002) ‘The complaint of a sudden, compelling desire to pass urine which is difficult to defer.’ more specific excludes a gradual build up of sensation as in bladder hypersensitivity or painful bladder (ref. ICS definition – 1988; urgency for fear of pain) A sensation that demands attention it also demands action assumes detrusor overactivity to be the cause

Urgency and Urge to Void : 

Urgency and Urge to Void Urgency is a symptom ‘Urge to void’ is an expression in common parlance (English) and is synonymous with ‘desire to void,’ which we all get Therefore, avoid the expression ‘urge to void’

ICS Course 4 : 

Paul Abrams (UK), Philip van Kerrebroeck (The Netherlands) ICS Course 4 TERMINOLOGY Symptoms and Symptom Syndromes Roger Dmochowski Signs Peter Sand Urodynamic Observations Derek Griffiths Conditions Peter Sand

Storage Symptoms (ICS 2002):Suggested modifications : 

Storage Symptoms (ICS 2002):Suggested modifications Urgency - is the complaint of a sudden compelling desire to pass urine, which is difficult to defer, for fear of leakage Urgency incontinence - is the complaint of involuntary leakage accompanied by or immediately preceded by urgency Increased Daytime Frequency - is the complaint by the patient who considers that he/she voids too often by day Nocturia - is the complaint that the individual has to wake at night one or more times to void

Urgency: changing the definition? : 

Urgency: changing the definition? Urgency is a (abnormal, or inappropriate) sudden, compelling desire to pass urine, which is (very) difficult (or impossible) to defer (for fear of leakage?) ICS 2004 Terminology Workshop decided to make no change

Lower Urinary Tract Symptoms : 

1.1 Storage symptoms 1.2 Voiding symptoms 1.3 Post micturition symptoms 1.4 Symptoms associated with sexual intercourse 1.5 Symptoms associated with pelvic organ prolapse 1.6 Genital and LUT pain 1.7 Genito urinary pain syndromes and symptom syndromes suggestive of LUT Dysfunction (LUTD) Lower Urinary Tract Symptoms

Syndromes : 

Syndromes cannot be used for precise diagnosis include at least two symptoms incidence of individual symptoms should be stated when describing a patient group with the syndrome presumed that other tests have excluded causes such as infective, neoplastic, metabolic or hormonal Syndromes describe constellations, or varying combinations of symptoms.

Symptom syndromes suggestive of LUTD : 

Symptom syndromes suggestive of LUTD Urgency, with or without urge incontinence, usually with frequency and nocturia Can be described as the overactive bladder syndrome, urge syndrome or urgency-frequency syndrome. LUTS suggestive of bladder outlet obstruction A term used when a man complains predominately of voiding symptoms in the absence of infection or obvious pathology other than possible causes of outlet obstruction.

Overactive Bladder Syndrome : 

Overactive Bladder Syndrome Definition Urgency, with / without urge incontinence Usually with frequency and nocturia Diagnosis based on symptoms alone Assumes no underlying organic pathology ICS 2002

Overactive Bladder (OAB) : 

Overactive Bladder (OAB) Strength : easily understood by patients and primary care staff. Weakness : must not become a ‘rag-bag’ diagnosis like ‘prostatism’ or ‘IC’.

Painful bladder syndrome : 

Painful bladder syndrome Painful bladder syndrome is the complaint of suprapubic pain related to bladder filling May be accompanied by other symptoms such as increased daytime and night-time frequency In the absence of proven urinary infection or other obvious pathology. A preferable term to “interstitial cystitis”. Interstitial cystitis is a specific diagnosis and requires confirmation by typical cystoscopic and histological features. In the investigation of bladder pain it may be necessary to exclude conditions such as carcinoma in situ and endometriosis.

Perineal pain syndrome : 

Perineal pain syndrome Perineal pain syndrome is the occurrence of persistent or recurrent episodic perineal pain May be related to the micturition cycle or associated with symptoms suggestive of urinary tract or sexual dysfunction. There is no proven infection or other obvious pathology

Signs : 

Signs are observed by the physician including simple means, to verify symptoms and quantify them. Signs classical sign e.g. leakage on coughing other signs (observations) include data from: frequency-volume chart pad testing quality of life questionnaires

Quantification of LUTS : 

Quantification of LUTS Charts and diaries Micturition time charts FVC Bladder diaries

Defining nocturnal polyuria : 

Defining nocturnal polyuria Relative indices ICS: more than 33% produced at night Nocturia Index > 1 Absolute index Asplund : > 0.9ml/minute

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Frequency-volume chart

Quantification of LUTS : 

Quantification of LUTS Determining the limits of normality Community surveys Both sexes, all age groups Statistical acceptance of limits, + two standard deviations? Should ICS have tackled this? Polyuria defined as >40ml/kg/24 hours

Pelvic floor muscle function : 

Pelvic floor muscle function Assessed by tone and strength of contraction (voluntary/reflex) ICS scale: strong, weak, absent Should ICS adopt “more precise” scale eg Oxford?

Pad Testing : 

Pad Testing Pad testing may be used to quantify the amount of urine lost during incontinence episodes and methods range from a short provocative test to a 24-hour pad test. Should ICS be recommending a specific test 1 hour? Bladder filling plus short test?

Urodynamic Observations : 

Urodynamic observations are observations made during urodynamic studies. Urodynamic Observations e.g. An involuntary detrusor contraction (detrusor overactivity) May have a number of underlying causes May occur with symptoms and/or signs May occur without symptoms and/or signs

ICS Classification of Urinary Tract Dysfunction : 

ICS Classification of Urinary Tract Dysfunction Storage Phase Bladder function detrusor activity bladder sensation bladder capacity bladder compliance Urethral function Voiding phase Detrusor function Urethral function

Filling Cystometry : 

3.2.1 Bladder Sensation 3.2.2 Detrusor function 3.2.3 Bladder compliance 3.2.4 Bladder capacity 3.2.5 Urethral function Filling Cystometry

ICS Classification : Storage Phase : 

ICS Classification : Storage Phase Detrusor activity normal overactive idiopathic detrusor overactivity neurogenic detrusor overactivity Bladder sensation normal increased reduced absent

ICS Classification : Storage Phase : 

ICS Classification : Storage Phase Bladder function Bladder capacity maximum cystometric capacity maximum anaesthetic bladder capacity Bladder compliance No precise data exist to define capacity and compliance as “High”, “Low” or “Normal”.

ICS Classification : Storage Phase : 

ICS Classification : Storage Phase Urethral function normal incompetent urodynamic stress incontinence inappropriate urethral relaxation

ICS Definition of Urodynamic Stress Incontinence : 

ICS Definition of Urodynamic Stress Incontinence the involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction

ICS Report 1988 Scand J. Urol. Nephrol. Suppl. 114 : 

ICS Report 1988 Scand J. Urol. Nephrol. Suppl. 114 6.1 The Storage Phase 6.1.1 Bladder function during storage 6.1.1.1 Detrusor activity Detrusor activity may be : (a) normal (b) overactive

ICS 1988 : 

ICS 1988 Overactive detrusor function is characterised by involuntary detrusor contractions during the filling phase, which may be spontaneous or provoked and which the patient cannot completely suppress. The unstable bladder Detrusor hyperreflexia

Detrusor Overactivity : 

Detrusor Overactivity ‘ a urodynamic observation characterised by involuntary detrusor contractions during the filling phase which may be spontaneous or provoked’ Abrams et al, 2002

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First Sensation of Filling First Desire to Void Urgency Detrusor Overactivity and Low Compliance

Detrusor Overactivity : 

Detrusor Overactivity Neurogenic ‘where there is a relevant neurological condition’ Idiopathic ‘when there is no defined cause’ Abrams et al, 2002

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Urodynamic definitions of detrusor overactivity (ICS 2002) Detrusor overactivity - phasic or terminal - idiopathic or neurogenic - symptomatic or asymptomatic Detrusor overactivity incontinence, can also be qualified

Neurogenic DO : 

Neurogenic DO

When is detrusor overactivity significant? : 

When is detrusor overactivity significant? When it causes the patient bothersome symptoms If it persists, and causes symptoms, after treatment - for stress incontinence - for benign prostatic obstruction In neurological patients ,when it may compromise upper tract function

When is detrusor overactivity not significant? : 

When is detrusor overactivity not significant? When it is asymptomatic When it is artefactual, perhaps due to the pressure of a catheter

Is detrusor overactivity abnormal? : 

Is detrusor overactivity abnormal? PROBABLY not Many of us have felt occasional true URGENCY As we get older many will have occasional URGE INCONTINENCE The high prevalence during ambulatory UDS in “normal” subjects is impressive BUT these individuals do not have bothersome symptoms

The Diagnosis of DO does not include : : 

The Diagnosis of DO does not include : patients with symptoms who have not had UDS patients with symptoms who have had UDS without the demonstration of DO patients with inappropriate urethral relaxation patients whose bladder neck is seen to be open with or without symptoms

Bladder Compliance : 

Bladder Compliance Is the terminology (bladder vs detrusor) correct? How should compliance be defined? pdet at zero volume pdet at cystometric capacity or before a detrusor contraction causing “significant leakage”

ICS Classification : Voiding Phase : 

ICS Classification : Voiding Phase Detrusor function normal underactive acontractile Urethral function normal obstructive overactive mechanical

ICS Classification : Voiding Phase : 

ICS Classification : Voiding Phase Urethral function Urethral overactivity detrusor-sphincter-dyssynergia detrusor-bladder neck-dyssynergia non-relaxing urethral sphincter obstruction dysfunctional voiding

ICS Terminology 2002: Symptom syndrome : 

ICS Terminology 2002: Symptom syndrome Urgency, with or without urge incontinence, usually with frequency and nocturia, can be described as the “overactive bladder syndrome”, “urge syndrome” or “urgency-frequency syndrome” These symptom combinations are suggestive of urodynamically demonstrable detrusor overactivity They can be due to other forms of vesico-urethral dysfunction These terms can only be used if there is no proveninfection or other obvious pathology

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Overactive Bladder Symptomatic diagnosis Detrusor Overactivity Urodynamic diagnosis Symptomatic vs Urodynamic Vs

New Definitions: NUU 2002 : 

New Definitions: NUU 2002 Overactive bladder Idiopathic detrusor overactivity Neurogenic detrusor overactivity Urodynamic stress incontinence No equivalent term Detrusor instability Detrusor hyperreflexia Genuine stress incontinence New Old

“Lost” terms : 

“Lost” terms Bladder instability Hyperreflexia Reflex incontinence Functional capacity Atonic / hypotonic bladder

Conditions : 

Conditions are defined by the presence of urodynamic observations associated with characteristic symptoms or signs and/or non-urodynamic evidence of relevant pathological processes. Conditions

Conditions : 

Conditions Acute retention of urine Painful palpable or percussable bladder when the patient is unable to pass any urine Chronic retention of urine A non painful bladder which remains palpable or percussable after the patient has passed urine (may be incontinent)

Treatments : 

Treatments Lower Urinary Tract Rehabilitation Pelvic floor training Biofeedback Behavioural modification Electrical stimulation Catheterisation Indwelling CISC

New Terminology : 

New Terminology LUTS instead of “prostatism” Storage instead of “irritative” Voiding instead of “obstructive”

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BAUS Guidelines : Male LUTS Does the patient have bothersome symptoms? Does the patient have nocturnal polyuria? Does the patient have overactive bladder symptoms? Does the patient have bladder outlet obstruction? Does the patient have risk of progression? THEN: decide the treatment according to the likely cause(s) of the symptoms BJU 2004

4. Lower Urinary Tract Conditions : 

4. Lower Urinary Tract Conditions Acute retention of urine Chronic retention of urine Benign prostatic obstruction Benign prostatic hyperplasia Benign prostatic enlargement Should also include? Detrusor overactivity incontinence Urodynamic stress incontinence Urethral relaxation incontinence

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Benign Prostatic Hyperplasia is a histological term THEREFORE the diagnosis is made with a microscope.

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What do you mean by: BPH Clinical BPH Symptomatic BPH Prostatism

Nomenclature does it really matter? : 

Nomenclature does it really matter? YES intellectual honesty scientific accuracy clinical management communication

Definitions: Conclusions : 

Definitions: Conclusions Revised definitions published ICS NUU 2002 New definitions intended to have greater intuitive meaning ICS definitions allow effective communication

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Manneken Pis - Brussels